The nurse plans care to prevent a dangerous thermal environment for an older adult client who lives in a northern climate of the United States. Which client assessment data does the nurse recognize that can contribute to the risk of hypothermia? (Select all that apply.)

A. "Side rails do not decrease falls, but they do decrease fall-related injuries."

Explanation: While side rails may reduce the severity of injuries if a fall occurs, they are not proven to decrease the overall rate of falls. Additionally, side rails themselves can pose risks, including entrapment.

B. There is no evidence that side rail use decreases falls, and in fact, there is a greater risk of injury."

Explanation: The use of side rails as a fall prevention measure has been associated with risks and has not been shown to effectively decrease the overall rate of falls. There is evidence that side rails can contribute to injuries, including entrapment, when patients attempt to climb over or through them. The focus in fall prevention has shifted towards individualized assessments, environmental modifications, and other strategies that address the specific needs and risks of each patient.

C. "Side rails are only effective when used with patients who have dementia."

Explanation: The effectiveness of side rails is not limited to patients with dementia. However, the use of side rails as a general fall prevention strategy has been questioned, and their use should be carefully considered based on individual assessments and risks.

D. "Side rails have only proven to be effective in decreasing falls in patients who have already fallen."

Explanation: The use of side rails is not universally proven to be effective in decreasing falls, even in patients who have previously fallen. The decision to use side rails should be based on a thorough assessment of the individual's needs and risks, considering alternatives to promote safety.

A. Tell her to use an assistive device until her balance improves.

Explanation: While using an assistive device may provide support, it is not a comprehensive solution for improving balance. Addressing balance issues usually involves a combination of exercises and interventions tailored to the individual's needs.

B. Provide information on group exercises for balance training.

Explanation: Group exercises specifically designed for balance training can be beneficial for an older adult who is recovering from balance issues and falls. These programs often include exercises targeting stability, coordination, and strength, and they are led by professionals who can provide guidance and supervision. Group exercises also offer a social component, promoting motivation and adherence to the program.

C. Instruct her to enroll in a general exercise program for 8 weeks.

Explanation: A general exercise program may not specifically focus on balance training. Tailoring the program to address balance issues is more appropriate for the client's needs.

D. Help her to learn how to exercise the core group of muscles.

Explanation: While exercising the core muscles can contribute to overall stability, a broader approach that includes balance-specific exercises is preferable for someone recovering from balance issues and falls. Balance training often involves exercises that target various muscle groups involved in maintaining stability.